Provider Demographics
NPI:1912065228
Name:FAZZALARO, WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:FAZZALARO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24411 HEALTH CENTER DR STE 680
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3692
Mailing Address - Country:US
Mailing Address - Phone:949-268-4568
Mailing Address - Fax:949-455-2795
Practice Address - Street 1:24411 HEALTH CENTER DR STE 680
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3692
Practice Address - Country:US
Practice Address - Phone:949-268-4568
Practice Address - Fax:949-455-2795
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16754363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750339479OtherGROUP NPI
CAPA16754OtherLICENSE
CAPA16754OtherLICENSE
CAMF0948212OtherDEA